Healthcare Provider Details

I. General information

NPI: 1154603264
Provider Name (Legal Business Name): SHANNON SULLIVAN SMITHSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 FREMONT BLVD STE E1
SEASIDE CA
93955-4319
US

IV. Provider business mailing address

1513 FREMONT BLVD STE E1
SEASIDE CA
93955-4319
US

V. Phone/Fax

Practice location:
  • Phone: 831-899-1910
  • Fax: 831-393-9483
Mailing address:
  • Phone: 831-899-1910
  • Fax: 831-393-9483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number21852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: